Differences In Prescription Research Articles

Antimicrobial Prescribing Patterns in GP Practices in Northern Ireland

Introduction: Antimicrobial resistance (AMR) is a global health threat requiring immediate attention as it is set to cause ten million deaths worldwide by 2050, overtaking that of cancer. Continuation of overuse and/or misuse of these crucial medicines will prevent future generations from reaping the benefits, as the pandemic of AMR spirals out of control. Aims: The primary aim of this study was to investigate antimicrobial prescribing patterns in General Practices throughout Northern Ireland. A secondary aim was to analyse the impact of the COVID-19 pandemic on antimicrobial prescribing and consumption patterns in GP practices in Northern Ireland. Methods: A retrospective, cross-sectional quantitative study was designed to measure, analyse, and evaluate the antimicrobial prescribing patterns within GP practices in Northern Ireland, using open access Business Services Organisation (BSO) data. Results: A total of 3,168.78 kg of antibacterial drugs were prescribed in primary care throughout the duration of the study. Penicillins were the most prescribed class (59.79%), followed by tetracyclines (10.68%) and macrolides (9.53%). Access group antibiotics were the most frequently prescribed (79.35%), followed by Watch group antibiotics (20.64%), with Reserve group antibiotics equating to nearly 0% despite being prescribed. The Derry GP Federation prescribed and dispensed the greatest amount of antibiotics overall in Northern Ireland (10.90%). Despite there being no significant difference in antibiotic prescribing amongst GP federations prior to and during the COVID-19 pandemic (unpaired t-test, p > 0.05), there were differences in prescribing of individual drug classes throughout this period. Conclusions: Despite meeting World Health Organisation (WHO) targets, GP practices within Northern Ireland must achieve more to further reduce antimicrobial consumption. Although antibiotic prescribing rates here are on the decline, there was no significant difference in prescribing amongst GP federations pre- and midst-COVID-19 pandemic, thus sufficient strategies such as increased communication between colleagues and supportive measures must be implemented within GP practices to enhance antimicrobial stewardship (AMS) across Northern Ireland.

Capitalizing on Implementation Science to Advance Antimicrobial Stewardship and Health Equity in Treating Pediatric UTI’s

Background: Pediatric urinary tract infections represent the most common pediatric infection with increasing gram-negative antibiotic resistance. Overutilization of antimicrobials including third generation cephalosporins are known drivers of this resistance. Antimicrobial stewardship (AS) efforts have recently shown that antibiotic selection may be influenced by patient race. Implementation science (IS) can provide frameworks and strategies to improve antimicrobial utilization and equity. Methods: This was a pre/post study of 2 geographically different children’s hospitals general pediatric floors assessing the impact of a set of implementation strategies developed to improve provider knowledge of best practice antimicrobials (based on local susceptibilities for treatment of UTI’s) and influence uptake of best practice prescribing. IS strategies included provider education, local clinical champion and opinion leader involvement, leadership involvement, local policy changes, and stakeholder co-design of decision support tools (a clinical pathway, a specific ITI antibiogram, and a dynamic order set). No education was provided regarding racial differences in prescribing habits. Outcomes were measured utilizing a portion of the RE-AIM Framework of assessing adoption of “Right” antibiotic, order set adoption, and equitable reach (racial differences in prescribing). Results: Hospital A and B had a first-generation cephalosporin prescription rate of 29.7% (n=441) and 20.6% (n-557) pre implementation and 44.6% (n=84) and 47.5% (n=118) post (p < 0 .001). Both hospitals also saw a significant reduction in third-generation cephalosporins. In Hospital A, APRN’s were more likely to prescribe a first generation cephalosporin (52.4%) than a DO (42.1%) or MD (26.4%) pre-implementation (p=0.004). In Hospital B, APRN’s were less likely to prescribe first generation cephalosporins (5.4%) than a DO (28.9%) or MD (19.4%) pre-implementation (p=0.004). No statistical significance was seen post implementation for antimicrobial selection by provider type for either hospital. Based on race, both hospitals had Black and Other patients receiving more first-generation cephalosporins while white patients were more likely to receive third-generation cephalosporins (p=0.033) pre implementation. No statistical significance was seen post implementation for antimicrobial selection based on race. No improvement was seen in order set utilization. Conclusion: With order set utilization not improving with implementation of new dynamic order set, other strategies such as education, clinical champion and opinion leader involvement, and provision of a local UTI antibiogram were likely contributors to the improvement in best antimicrobial for treatment of UTI’s. Further mixed method research is warranted to improve understanding of the relative performance of our strategies, especially the lack of provider adoption of the novel dynamic order set.Disclosure: Jessica Snowden: Advisory board - Pfizer

GP registrars' deprescribing in older patients: a non-randomised controlled study.

Purpose: To evaluate the effect of a multi-component educational program aimed at improving general practitioner (GP) trainees’ (registrars') deprescribing in patients 65 years and over. The hypothesis was that an educational program would increase registrars' deprescribing of potentially inappropriate medicines (PIMs) in older patients, relative to a control group, six months post-education. Design: This was a pragmatic, non-randomised, non-equivalent control group design nested within an ongoing cohort study of registrars' practice (the ReCEnT study). The program consisted of an online module, face-to-face sessions for registrars, webinars for their supervisors, and facilitation of the registrar–supervisor dyad, including case-based discussions of deprescribing in teaching meetings. The program was underpinned by the Behaviour Change Wheel framework and delivered to registrars of a single registrar educational/training organisation (other educational/training organisations served as controls). Primary outcome measures were deprescribing any medicines and deprescribing medicines categorised as PIMs. Secondary outcomes were deprescribing of medications taken for three months or more and dose reduction with a view to deprescribing (cessation). Findings: Data from 779 education-receiving registrars and 438 control registrars were analysed. Intervention group registrars showed no significant increase in deprescribing of any medication compared to controls (interaction aOR 1.00 (95%CI 0.69, 1.46) or of PIMs (aOR 1.29 (95%CI 0.74, 2.24), or significant changes in secondary outcomes. Research implications: Despite no differences in prescribing, in this analysis, six months post-intervention, aspects of the findings suggest extended observation and further evaluation may be indicated. Practical implications: The continuation of education for registrars around deprescribing of PIMs is essential. Further investigation is required to assess the effectiveness and efficiency of the behaviour change approach adopted in this study. Originality/value: The multi-component behaviour change theory-based approach is novel for this educational setting, and this is an initial step in evaluating the approach. Limitations: The major limitation is that randomisation in the study design was not practicable.

P098 Changes in Analgesic Prescribing in Patients with Inflammatory Arthritis in England: An Observational Study in CPRD Aurum

Abstract Background/Aims Pain is a common symptom experienced by patients with inflammatory arthritis (IA). Emerging data indicate IA pain treatment focuses on prescribing analgesics despite an absence of evidence for long-term efficacy. Delivering optimal, equitable IA pain care in England requires understanding current practice. To address this, we evaluated analgesic prescribing in patients diagnosed with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA) contributing data to the Clinical Practice Research Datalink Aurum, a primary care electronic health record database covering 20% of England. Methods Cross-sectional analyses (2004-2020) evaluated the annual prevalence of analgesic prescriptions in patients with RA/PsA/axial SpA. These were reported stratified by age, gender, ethnicity, deprivation, and geographical region. Analgesic prescriptions were classified using Bedson et al’s hierarchical system with an additional gabapentinoid group. Joinpoint regression models evaluated time-points when a significant change in the trends of prescription annual prevalence occurred. Results Although declining over time, the annual prevalence of analgesic prescriptions remained high (84.2% [95% CI 83.9, 84.5] in 2004; 64.5% [95% CI 64.2, 64.8] in 2020). In 2004, oral NSAIDs were the commonest analgesic (prevalence 56.1% [95% CI 55.8, 56.5]). By 2020, this fell to 22.3% (95% CI 22.1, 22.6) with opioids being the commonest analgesic (prevalence 39.0% [95% CI 38.7, 39.2]). Most opioid prescriptions were “strong/very strong” and long-term. Annual prevalence of non-NSAID analgesic prescriptions was highest in RA and of NSAIDs was highest in axial SpA. The annual prevalence of all analgesic types except NSAIDs differed by age, sex, deprivation, ethnicity, and region. Annual prevalence of non-NSAID analgesic prescriptions increased with age and deprivation, were higher in females than males, and higher in Northern than Southern England. The opposite pattern was seen with age for oral NSAIDs. NSAIDs were more commonly prescribed in males than females. Very little difference was seen in NSAID prescribing by deprivation, ethnicity, and region. There was a significant change in the trend of opioid prescription annual prevalence in 2015 (year of Public Health England’s “Opioid Aware” release) when the rate of decline increased, and at 2013 and 2018 for gabapentinoids when the annual prevalence increase slowed then declined (years of NHS England’s release of information on gabapentinoid risks, and their reclassification as controlled substances). Conclusion Whilst overall national analgesic prescribing in IA has fallen over 17 years - with interventions to deliver safer opioid/gabapentinoid prescribing potentially contributing - it remains common. This is at variance with evidence of analgesic efficacy and risks. The differences in prescribing of some analgesic types by patient sociodemographic factors and regions suggest unwarranted variation. Interventions are needed to improve the delivery of effective, equitable IA pain treatment. Disclosure I.C. Scott: None. R. Whittle: None. J. Bailey: None. H. Twohig: None. S.L. Hider: None. C.D. Mallen: None. S. Muller: None. K.P. Jordan: None.

Association Between Open Payments–Reported Industry Transfers of Value and Prostaglandin Analog Prescribing in the US

Reported transfers of value (TOV) from pharmaceutical companies have been associated with greater use of branded anti-vascular endothelial growth factor agents by ophthalmologists, but payment under the Medicare Part B buy-and-bill model includes a financial incentive to choose costlier agents, potentially confounding analyses of pharmaceutical TOV and prescribing patterns. How these reported TOV are associated with prescribing patterns for prescription eye drops, not subject to the incentives created by Part B payments, should be considered. To assess the association between prostaglandin analog (PGA) eye drop prescribing and reported nonresearch TOV by makers of branded PGAs to US vision care professionals. This retrospective cohort analysis used a 20% nationally representative sample of 2018 Medicare Part D claims and industry TOV reported to the Open Payments program. Optometrists and ophthalmologists who had more than 10 claims for PGA drops in the 20% sample were analyzed. Analysis took place from June 2021 to February 2022. Multivariable logistic regression assessing the association between membership in strata of reported TOV and branded PGA prescribing rate, controlling for prescriber demographic factors, local area practices, total PGA prescribing volume, and plan formularies involved. A total of 20 612 ophthalmologists and 5426 optometrists (7449 [29%] female and 18 589 [71%] male) prescribed PGA eye drops. Of these, 9685 (37%) were reported to have received TOV from manufacturers of branded PGAs in 2018, totaling $5 060 346. The median (IQR) reported TOV was $65 ($24-$147). Multivariable logistic regression showed that the predicted probability of primarily prescribing branded PGAs among prescribers who reported receiving no TOV was 12.9% (95% CI, 12.4%-13.4%). This figure increased to 19.6% (95% CI, 18.8%-20.4%) among prescribers receiving TOV, a 50% increase. There was a dose-response association, such that the top 10% of TOV recipients had a 29.2% probability (95% CI, 26.4%-31.9%) of preferential branded use. While the median reported TOV to a PGA prescriber was relatively low in this study, there was a positive association between amount of reported nonresearch TOV received from PGA makers and the frequency of branded PGA use. This shows that small reported TOV were associated with differences in prescribing. High rates of branded PGA prescribing may pose a cost burden to patients that affects adherence. Clinicians and policy makers should be aware of these associations.

Retrospective, cohort review of pharmacists' impact on disparities in care in the management of type 2 diabetes with glucagon‐like peptide‐1 agonists and sodium glucose co‐transporter 2 inhibitors

AbstractBackgroundThe American Diabetes Association recommend glucagon‐like peptide‐1 (GLP‐1) agonists and sodium glucose co‐transporter 2 (SGLT‐2) inhibitors be considered as first‐line therapy for type 2 diabetes. A secondary analysis of the Look AHEAD study determined these agents are disproportionately prescribed at higher rates to White patients compared with Black patients.ObjectivesThe objective of this study is to evaluate if a disparity exists between the prescribing of SGLT‐2 inhibitors and GLP‐1 agonists between White patients and Black patients at an academic, safety‐net health system.MethodsA single‐center retrospective chart review was conducted on patients seen at a pharmacist‐managed or provider‐managed clinic. The primary outcome is the difference in prescribing of SGLT‐2 inhibitors and GLP‐1 agonists between Black and White patients in the pharmacist and provider‐managed group. Secondary outcomes include differences in prescribing in Hispanic patients and patients with a serious mental illness.ResultsThe primary outcome of prescribing rates for GLP‐1 agonists and SGLT‐2 inhibitors did not differ significantly in the pharmacist comanaged group. The primary outcome in the provider managed group did differ significantly. The largest prescribing rate was in the “other” race category. Only two variables were found in the combined datasets to play a role in the prescribing of a GLP‐1 agonist or SGLT‐2 inhibitor. Having only a provider and not a pharmacist involved in care was predictive of not being prescribed either agent (odds ratio = 0.096, P = <.001). Insurance status was the other statistically significant predictor of being prescribed a GLP‐1 agonist or SGLT‐2 inhibitor (odds ratio = 1.592, P = .006).ConclusionA clinically significant difference in prescribing based on race did not exist in the pharmacist comanaged group or the provider only managed group. Pharmacist involvement and insurance status appear to have a positive impact on an SGLT‐2 inhibitor or GLP‐1 agonist being prescribed.

Sex Differences in Potentially Inappropriate Prescribing Among Older Adults With Multimorbidity

Sex differences in prescribing potentially inappropriate medications (PIMs) for various multimorbidity patterns are not well understood. This study sought to identify sex specific risk of PIMs in older adults with cardiovascular-metabolic patterns. Secondary analysis of the Health and Retirement Study interview data (2004-2014; n=6,341, ≥65 y/o) linked to Medicare claims data was conducted. Four multimorbidity patterns were identified based on the list of 20 chronic conditions and included: ‘cardiovascular-metabolic only’, ‘cardiovascular-metabolic plus other physical conditions’, ‘cardiovascular-metabolic plus mental conditions’, and ‘no cardiovascular-metabolic disease’ patterns. Presence of PIM prescribing was identified using the 2015 American Geriatrics Society Beers Criteria, limited to the list of medications to avoid in older adults. Chi-square tests and logistic regressions were used to identify sex differences in prescribing PIMs across multimorbidity patterns: (1) for PIMs overall and (2) for each PIM drug class. Results indicate that on average women were prescribed PIMs more often than men (39.4% and 32.8%, respectively). Women with cardiovascular-metabolic plus other physical patterns (Adj.OR=1.25, 95% CI: 1.07-1.45) and cardiovascular-metabolic plus mental patterns (Adj.OR=1.25, 95% CI: 1.06-1.48) had higher odds of PIM compared to men, however, there were no sex differences in PIM prescribing in the cardiovascular-metabolic only patterns (Adj.OR=1.13, 95% CI: 0.79-1.62). There was variation by sex across different PIM drug classes. Our study emphasizes the need to further reduce PIM prescribing among older adults, and identifies target populations for potential interventions to improve medication prescribing practices.

Examination of physician characteristics in opioid prescribing in the emergency department.

We aimed to better understand variation in opioid prescribing practices by investigating physician factors at one academic suburban Emergency Department (ED). We retrospectively reviewed the electronic medical records of all patients given opioid prescriptions in the Stanford Health Care ED from 2009 to 2018. We described the variation in opioid prescriptions over time from 2009 to 2018, then dove deeper into a single year (July 1, 2017 to July 1, 2018). We described the number and type of opioid prescriptions at discharge and variation in attending physician opioid prescribing patterns using independent t-tests and a Fischer's exact test. From 2009 to 2018, 657,037 patient visits occurred; 92,612 (14.1%) opioid prescriptions were written. Opioid prescriptions increased from 2009, peaked in 2015, then decreased. Individual providers wrote opioid prescriptions for 1 to 17% of their discharged patients. There was no significant difference in opioid prescribing based on provider gender (p = 0.456), fellow or attending status (p = 0.390), residency completed at Stanford Hospital (p = 0.593), residency completed within California (p = 0.493), or residency completed after 2010 (p = 0.589). Of the 371 providers who wrote opioid prescriptions from 2009 through 2018, 120 wrote prescriptions for patients who had already received at least three opioid prescriptions in the same year from the same department. This study could inform policymakers by describing patterns of variation in opioid prescribing over time and between providers. Although we did see significant differences in prescribing patterns from one provider to the next, those were not explained by the factors we examined. Further studies could investigate factors such as provider experience with pain and addiction, bias regarding particular pathologies, and concern around patient satisfaction scores.

Rural differences in psychiatric medication prescribing in veterans with posttraumatic stress disorder.

Disparities in the treatment of posttraumatic stress disorder (PTSD) for rural veterans have been noted in prior research. The objective was to examine rural differences in prescribing for veterans with PTSD, and changes over time, in the Department of Veterans Affairs (VA) health care system. Prescribing prevalence in veterans with PTSD during 2009 and 2019 was determined using national VA administrative pharmacy data according to the joint VA-Department of Defense clinical practice guideline as medications recommended for use in PTSD and those recommended against use. Multivariable logistic regression was used to contrast patient residence (urban vs rural) and site of PTSD care (medical center, urban clinic, or rural clinic), while adjusting for clinical covariates. Recommended medications were prescribed significantly less often to patients of rural clinics, relative to medical centers in 2009 (OR = 0.91; 95% CI: 0.89-0.94) but reached equivalence in 2019 (OR = 1.01; 95% CI: 0.99-1.03). In addition, rural clinics had significantly lower prescribing of recommended against medications (OR = 0.86; 95% CI: 0.84-0.87) in 2019. Prescribing of medications recommended against the use for PTSD was higher among rural residents, relative to urban residents in 2009 (OR = 1.14; 95% CI: 1.12-1.16), which declined toward equivalence by 2019 (OR = 1.06; 95% CI: 1.05-1.07). While some clinically meaningful differences in prescribing for rural veterans with PTSD were observed in 2009, these differences shifted toward equivalency within the following decade. In 2019, we failed to observe any systematic prescribing deficiencies for veterans receiving PTSD care at rural clinics.

HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management.

Electronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs). To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5-10.5% managed by PCPs. Cluster-randomized matched cohort study with implementation evaluation. PCPs affiliated with Massachusetts General Hospital (MGH). Unsolicited endocrinology eConsultation. The primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits. 161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs -3.1%, p=0.03) and sulfonylureas (1.5% vs -6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications. The implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c. Clinicaltrials.gov registration: NCT03542084.

An investigation of new medications initiation during ambulatory care visits in patients with dementia

BackgroundThere is currently insufficient data describing how new medications are provided to older adult ambulatory patients with dementia in the United States (US). ObjectivesTo describe characteristics of ambulatory care visits for adults ≥65 years old and investigate differences in prescribing of new medications between patients with and without dementia. MethodsWe conducted a population-based cross-sectional study using the 2016 National Ambulatory Medical Care Survey (NAMCS) in the US. Non-perioperative ambulatory care visits of patients ≥65 years old with sampling weights were used to provide national estimates of visits. Baseline characteristics were compared between visits for patients with and without dementia using Pearson's chi square or Student's t-tests. We used multivariable logistic regression to estimate the odds of receiving a new medication. Results218,182,131 non-perioperative ambulatory care visits of patients ≥65 years old were included, 2.1% of which were for patients with dementia; these patients were older on average and had more comorbidities and higher ambulatory care utilization than those without dementia. New medications were provided at 26.3% of visits for patients with dementia. After adjusting for confounders, there was no statistically significant difference in odds of a new medication being provided between visits for patients with and without dementia (odds ratio [OR], 0.555; 95% confidence interval [CI], 0.183–1.678). Differences were seen in the provision of cholinesterase inhibitors, antipsychotics, and central nervous system agents at visits for patients with dementia (p = 0.0011, <0.0001, and 0.0011 respectively). ConclusionWhile fewer visits for patients with dementia provided new medications compared to patients without dementia, after adjusting for confounders no significant difference were identified. Significant differences were seen in the classes of new medications provided. Further investigation is needed to evaluate new medication usage and the utility of pharmacists in the care of patients with dementia at an outpatient setting.

Are there sex differences in potentially inappropriate prescribing in adults with multimorbidity?

Limited knowledge exists regarding sex differences in prescribing potentially inappropriate medications (PIMs) for various multimorbidity patterns. This study sought to determine sex differences in PIM prescribing in older adults with cardiovascular-metabolic patterns. Retrospective cohort study. Health and Retirement Study (HRS) 2004-2014 interview data, linked to HRS-Medicare claims data annualized for 2005-2014. Six thousand three-hundred and forty-one HRS participants aged 65 and older with two and more chronic conditions. PIM events were calculated using 2015 American Geriatrics Society Beers Criteria. Multimorbidity patterns included: "cardiovascular-metabolic only," "cardiovascular-metabolic plus other physical conditions," "cardiovascular-metabolic plus mental conditions," and "no cardiovascular-metabolic disease" patterns. Logistic regression models were used to determine the association between PIM and sex, including interaction between sex and multimorbidity categories in the model, for PIM overall and for each PIM drug class. Women were prescribed PIMs more often than men (39.4% vs 32.8%). Overall, women had increased odds of PIM (Adj. odds ratio [OR]=1.30, 95% confidence interval [CI]: 1.16-1.46). Women had higher odds of PIM than men with cardiovascular-metabolic plus physical patterns (Adj. OR=1.25, 95% CI: 1.07-1.45) and cardiovascular-metabolic plus mental patterns (Adj. OR=1.25, 95% CI: 1.06-1.48), and there were no sex differences in adults with a cardiovascular-metabolic only patterns (Adj. OR=1.13, 95% CI: 0.79-1.62). Women had greater odds of being prescribed the following PIMs: anticholinergics, antidepressants, antispasmodics, benzodiazepines, skeletal muscle relaxants, and had lower odds of being prescribed pain drugs and sulfonylureas compared with men. This study evaluated sex differences in PIM prescribing among adults with complex cardiovascular-metabolic multimorbidity patterns. The effect of sex varied across multimorbidity patterns and by different PIM drug classes. This study identified important opportunities for future interventions to improve medication prescribing among older adults at risk for PIM.

Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration (VHA)

Use of nonbenzodiazepine sedative hypnotics, especially zolpidem, has grown substantially, raising concerns about safety. Gender‐specific guidelines have been recommended for appropriate zolpidem prescribing to address patient safety concerns. In line with an FDA recommendation in 2013, the Veterans Health Administration (VHA) issued a similar directive to lower the doses of zolpidem in women in 2013. However, little is known about zolpidem prescribing patterns in the VHA in general. Therefore, the goal of this study was to examine utilization trends and inappropriate prescribing of zolpidem in accordance with VHA guidelines in male and female veterans in the VHA.A cross‐sectional study of veterans receiving zolpidem in the outpatient setting from October 1, 2011, to September 30, 2016. We examined 2 outcomes related to inappropriate zolpidem prescribing: high‐dose and overlap with benzodiazepines.The study population consisted of 500 332 zolpidem users (58 598 women and 441 734 men) and a random 10% sample (n = 631 449) of nonusers.Across the VHA, 7.1% of men and 10.0% of women received zolpidem at least once during the study period. In 2016, 29.7% of female veterans received an inappropriately high guideline‐discordant dosage compared with 0.1% of male veterans (P &lt; .001 for all reported comparisons). Furthermore, more women than men had overlapping benzodiazepine and zolpidem prescriptions (18.8% vs 14.3%). In unadjusted trends in high‐dose zolpidem prescriptions by gender before and after the VHA 2013 recommendations for suggested lower dose in women, we found that the observed proportion of women receiving the higher dose decreased considerably from 75.9% in 2011 to 29.1% in 2016. For men also, there was a decline in observed receipt of high‐dose zolpidem from 1.7% in 2011 to 0.1% in 2016. In fully adjusted models, inappropriately high doses were more commonly received by younger women (adjusted odds ratios [AORs]: 2.75 for 21‐39 years and 2.97 for 40‐49 years compared with ≥ 80 years) and women with substance use disorder (AOR, 1.48). In the second inappropriateness outcome models, women with anxiety (AOR, 2.28) or schizophrenia (AOR, 2.05) and men with cancer (AOR, 1.42), anxiety (AOR, 2.66), or schizophrenia (AOR, 2.46) were more likely to receive an overlapping prescription of zolpidem and benzodiazepines.We found inappropriate prescribing of zolpidem, in terms of both guideline‐discordant dosage and coprescribing with benzodiazepines, with female Veterans affected more than male Veterans. Potential contributors to this inappropriate prescribing of zolpidem in women could include the fact that the majority of patients served by the VHA are men. Hence, providers may be less familiar with issues specific to treating female veterans.Findings have implications both for patient safety and promoting guideline‐concordant prescribing in female zolpidem users, specifically those with existing mental conditions. These findings may help guide and inform intervention efforts targeted toward these female Veterans to optimize zolpidem prescribing in the VHA. Greater understanding of the drivers of this inappropriate prescribing is necessary to develop interventions to promote safer, more guideline‐concordant prescribing.Department of Veterans Affairs.

International prescribing patterns and polypharmacy in older people with advanced chronic kidney disease: results from the European Quality study.

People with chronic kidney disease (CKD) are at high risk of polypharmacy. However, no previous study has investigated international prescribing patterns in this group. This article aims to examine prescribing and polypharmacy patterns among older people with advanced CKD across the countries involved in the European Quality (EQUAL) study. The EQUAL study is an international prospective cohort study of patients ≥65 years of age with advanced CKD. Baseline demographic, clinical and medication data were analysed and reported descriptively. Polypharmacy was defined as ≥5 medications and hyperpolypharmacy as ≥10. Univariable and multivariable linear regressions were used to determine associations between country and the number of prescribed medications. Univariable and multivariable logistic regression were used to determine associations between country and hyperpolypharmacy. Of the 1317 participants from five European countries, 91% were experiencing polypharmacy and 43% were experiencing hyperpolypharmacy. Cardiovascular medications were the most prescribed medications (mean 3.5 per person). There were international differences in prescribing, with significantly greater hyperpolypharmacy in Germany {odds ratio (OR) 2.75 [95% confidence interval (CI) 1.73-4.37]; P < 0.001, reference group UK}, the Netherlands [OR 1.91 (95% CI 1.32-2.76); P = 0.001] and Italy [OR 1.57 (95% CI 1.15-2.15); P = 0.004]. People in Poland experienced the least hyperpolypharmacy [OR 0.39 (95% CI 0.17-0.87); P = 0.021]. Hyperpolypharmacy is common among older people with advanced CKD, with significant international differences in the number of medications prescribed. Practice variation may represent a lack of consensus regarding appropriate prescribing for this high-risk group for whom pharmacological treatment has great potential for harm as well as benefit.

National gender differences in the prescribing of opioid medications from 2006 to 2015.

To identify gender differences in opioid prescribing from ambulatory care settings and identify factors associated with prescribing of opioids for men and women. Retrospective analysis of data from The National Ambulatory Medical Care Survey from January 1, 2006 to December 31, 2015. Eligible patients were at least 18 years old on the date of the physician office visit. Data were collected on patient demographics and clinical factors. Data were analyzed using bivariate and multivariate logistic regression models to explore differences in opioid prescribing among men and women. Due to the large sample size, the significance level was set to p < 0.001. Opioid prescribing during an office visit. A total of 322 957 ambulatory care visits for adults were included in the analysis representing 7.8 billion weighted visits nationally. In 771 601 088 (9.8 percent) visits, an opioid was prescribed. Women received an opioid prescription at 9.4 percent of visits compared to 10.4 percent of visits for men. Gender differences for factors including age, region, payment method, and pain diagnosis were observed (p < 0.001). Women had a higher number of visits with an opioid (449 277 925 vs 322 323 163), but men had higher odds of being prescribed an opioid (OR: 1.214; CI: 1.214-1.214). Men are more likely to be prescribed an opioid as compared to women, but women are being prescribed more opioids overall. Gender differences should be further explored to develop gender-specific interventions to reduce opioid prescribing.

Abstract 332: Racial Differences in Prescribing of Sodium Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide-1 Receptor Agonists Among Veterans With Type 2 Diabetes and Coronary Artery Disease: Findings From the Veteran’s Administration Clinical Assessment, Reporting, and Tracking Program

Background: Recent trials have shown improved cardiovascular benefit associated outcomes with sodium glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) treatment in patients (pts) with type 2 diabetes (T2D) and high cardiovascular (CV) risk. We examined the extent to which this new evidence has been applied in routine clinical care and whether race influenced differences in prescription rates between patients. Methods and results: We used data from the US Department of Veterans Affairs’ Clinical Assessment, Reporting, and Tracking (CART) Program (2015-2017 inclusive). Pts were deemed SGLT2i- or GLP-1RA-eligible based on EMPA-REG OUTCOME and LEADER trial criteria. Rates of use were examined among eligible pts by race/ethnicity in unadjusted and multivariable logistic regression models adjusted for age, insurance type, service connection, and clinical site. From 84 sites, 21,053 patients were eligible for an SGLT2i and 1,520 (7.2%) had one prescribed. Recipients of SGLT2i were younger (65.59 years vs 68.29 years) had a higher mean HbA1c (8.27% vs 8.02%) and were more likely white (86.0 % vs 82.6%). Compared to black pts, whites had higher odds of receiving the medication, OR = 1.38; 95% CI 1.05,1.85; p &lt; 0.01. Among 11,913 Veterans eligible for an GLP-1RA, 477 (4.0%) had one prescribed. Recipients were younger (65.84 years vs 68.96 years), had a higher mean HbA1c (8.55% vs 8.09%) and were more likely white (83.6% vs 81.8%). Compared to black pts, whites had higher odds of receiving the medication, OR = 1.43; 95% CI 1.09, 1.92; p = 0.013. Representation of other racial/ethnic groups was insufficient for comparison. Conclusion: Appropriate prescription of SGLT2i or GLP-1RA was less likely among black than white US Veterans at high CV risk. Our results suggest that while overall uptake of these medications has been slow, there are substantial racial differences that exist concerning the prescribing of these medications. In view of these findings, additional research is needed to further investigate both institutional and clinical factors which may adversely affect the prescribing of SGLT2i and GLP-1RA in African American Veterans.

Evaluating Prevalence and Patterns of Prescribing Medications for Depression for Patients With Obesity Using Large Primary Care Data (Canadian Primary Care Sentinel Surveillance Network).

Introduction: Depression is a serious disorder that brings a tremendous health and economic burden. Many antidepressants (AD) have obesogenic effects, increasing the population of obese patients at increased risk for a more severe disease course and poor treatment response. In addition, obese patients with depression may not be receiving the recommended standard of care due to “obesity bias.” It is important to evaluate prescribing pharmacological treatment of depression in patients with obesity.Objectives: To describe the prevalence and patterns of AD prescribing for patients with depression and comorbid obesity compared with normal weight patients, and to examine the association of prescribing prevalence with obesity class.Methods: Study sample of adult patients (>18 years old) with depression was extracted from the national Canadian Primary Care Sentinel Surveillance Network (CPCSSN) Electronic Medical Records database for 2011–2016. Measures were prescribing of at least one AD (outcome) and body mass index (BMI) to categorize patients into weight categories (exposure). Data were analyzed cross-sectionally using descriptive statistics and mixed effects logistic regression model with clustering on CPCSSN networks and adjusting for age, sex, and the comorbidities.Results: Of 120,381 patients with depression, 63,830 patients had complete data on studied variables (complete cases analysis). Compared with normal weight patients, obese patients were more likely to receive an AD prescription (adjusted Odds Ratio [aOR] = 1.17; 95% Confidence Interval [CI]: 1.12–1.22). Patients with obesity classes II and III were 8% (95% CI: 1.00, 1.16) and 6% (95% CI: 0.98, 1.16) more likely, respectively, to receive AD. After imputing missing data using Multiple Imputations by Chained Equations, the results remained unchanged. The prevalence of prescribing >3 AD types was higher in obese category (7.27%, [95% CI: 6.84, 7.73]) than in normal weight category (5.6%; [95% CI: 5.24, 5.99]).Conclusion: The association between obesity and high prevalence of AD prescribing and prescribing high number of different AD to obese patients, consistent across geographical regions, raises a public health concern. Study results warrant qualitative studies to explore reasons behind the difference in prescribing, and quantitative longitudinal studies evaluating the association of AD prescribing patterns for obese patients with health outcomes.

Improved Antibiotic Prescribing within a Veterans Affairs Primary Care System through a Multifaceted Intervention Centered on Peer Comparison of Overall Antibiotic Prescribing Rates.

Reducing inappropriate outpatient antibiotic use is an important national goal. Limited data exist on targeted education and peer comparison of overall antibiotic prescribing rates as an antimicrobial stewardship strategy. Primary care professionals (PCPs) from all seven clinics within our health care system were offered an education session, followed by monthly e-mails with their antibiotic prescribing rate, peer prescribing rates, and a system target. A pre-post analysis was conducted to compare prescribing rates during the intervention period (January to June 2017) to a seasonal baseline (January to June 2016) using a regression model. A random sample of prescriptions was reviewed for adherence to consensus guidelines. Educational sessions were attended by 68.5% (50/73) of PCPs. From the baseline to the intervention period, the mean rate of monthly antibiotic prescriptions declined from 76.9 to 49.5 per 1,000 office visits (35.6% reduction [P < 0.001]). Among reviewed cases, unnecessary antibiotic prescribing declined (58.8% [80/136] versus 38.9% [70/180]; 33.9% reduction [P = 0.0006]), and the rate of optimally prescribed antibiotics increased (19.9% [27/136] versus 30% [54/180]; 50.8% increase [P = 0.05]). If an antibiotic was indicated, there were no significant differences in prescribing of guideline-discordant agents (21.4% [12/56] versus 19.1% [21/110] [P = 0.8]) or guideline-concordant agents for a guideline-discordant duration (38.6% [17/44] versus 39.3% [35/89] [P = 1]). There were significant reductions in azithromycin and fluoroquinolone prescriptions (50.9% and 59.4% [P values of <0.001], respectively), but most prescriptions for these agents in the intervention period remained inappropriate. Initial education followed by monthly peer comparison of overall antibiotic prescribing rates reduced total and unnecessary antibiotic prescribing in primary care clinics.

P3841Real world outcomes for clopidogrel versus ticagrelor treated patients with acute coronary syndrome: a systematic literature review and meta-analysis

Abstract Introduction The ischemic benefit of ticagrelor over clopidogrel seen in randomized trials has not been fully reproduced in real world cohorts. The discrepancy between these two treatments may be influenced by differences in prescribing. Purpose To provide insights in patient care for patients with high levels of comorbidities. Methods A systematic literature review and meta-analysis were conducted to compare clinical outcomes for clopidogrel vs. ticagrelor in real-world populations with acute coronary syndrome. MEDLINE and Embase were searched from inception to January 2018. Pairwise meta-analyses were performed using unadjusted random-effects models for both outcomes and patient characteristics to test for differences. Heterogeneity was assessed using the I2 statistic. Results The search identified 17 studies for analysis from 1,771 publications (TOTAL N=66,198; CLO N=54,175; TIC N=12,023). Clopidogrel-treated patients were more likely to have diabetes (33% vs. 24%), hypertension (59% vs. 47%), hyperlipidaemia/dyslipidaemia (45% vs. 39%), and prior stroke/transient ischemic attack (TIA) (8% vs. 5%). A slightly higher risk of myocardial infarction (MI) was observed for clopidogrel (4.5% vs. 3.5%; OR 1.29 [1.15–1.46]) and included clopidogrel patients had significantly more comorbidities (Figure 1). No statistical difference between clopidogrel and ticagrelor was found for risk of MACE, defined as the composite of cardiovascular (CV) death, MI or stroke, (13.6% vs. 10.1%; OR 1.41 [95% confidence interval 0.93–2.14]), despite clopidogrel patients having significantly more diabetes and hypertension (p≤0.01). Similarly, the risks of CV death (2.3% vs. 2.1%; OR 1.11 [0.58–2.13]), stroke (1.2% vs. 1.1%; OR 1.11 [0.56–2.17]), and stent thrombosis (1.3% vs. 1.0%; OR 1.34 [0.88–2.06]) were not statistically differentiable, despite clopidogrel patients having significantly more hyperlipidaemia in studies analysed for CV death (p&lt;0.05); significantly more diabetes, hypertension, peripheral arterial disease (PAD), hyperlipidaemia, and prior stroke/TIA in studies analysed for stroke (p&lt;0.05); and significantly more hyperlipidaemia and prior stroke/TIA in studies analysed for stent thrombosis (p&lt;0.01). There were no significant differences in all bleeding events (major or minor, as defined by study) (2.0% vs. 2.7%; OR 0.74 [0.54–1.00]) or major bleeding (2.9% vs. 2.7%; OR 1.07 [0.85–1.33]). Included clopidogrel patients had significantly more diabetes, hypertension, PAD, and prior stroke/TIA (p&lt;0.05). Significant heterogeneity (I2 &gt;60%) was observed for MACE, CV death, stroke and bleeding. Figure 1. Comorbidities in MI Conclusion This analysis suggests clopidogrel-treated patients had more comorbidities than ticagrelor-treated patients, which may introduce a bias with negative impact on their outcomes. Despite this circumstance, with the exception of MI, this analysis showed no statistical difference in efficacy and safety between clopidogrel and ticagrelor. Acknowledgement/Funding This analysis was funded by Sanofi.

Veterans Affairs Providers' Beliefs About the Contributors to and Responsibility for Reducing Racial and Ethnic Health Care Disparities.

Purpose: Providers' beliefs about the causes of disparities and the entities responsible for addressing these disparities are important in designing disparity-reduction interventions aimed at providers. This secondary analysis of a larger study is aimed at evaluating perceptions of providers regarding the underlying causes of racial health care disparities and their views of who is responsible for reducing them.Methods: We surveyed 232 providers at 3 Veterans Affairs (VA) Medical Centers.Results: Sixty-nine percent of participants believed that minority patients in the United States receive lower quality health care. Most participants (64%) attributed differences in quality of care for minority patients in the VA health care system primarily to patients' socioeconomic status, followed by patient behavior (43%) and provider behaviors (33%). In contrast, most participants believed that the VA and other health care organizations (75%) and providers (70%) bear the responsibility for reducing disparities, while less than half (45%) believed that patients were responsible. Among provider-level contributors to disparities, providers' poor communication was the most widely endorsed (48%), while differences in prescribing of medications (13%) and in provision of specialty referrals (12%) were the least endorsed.Conclusions: Although most providers in the study did not believe that providers contribute to disparities, they do believe that they, along with health care organizations, have the responsibility to help reduce them. Interventions might focus on directly offering providers concrete ways that they can help reduce disparities, rather than focusing on simply raising awareness about disparities and their contributions to them.